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Neonatal Subgaleal Haemorrhage Practice Recommendation

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Neonatal Subgaleal Haemorrhage Practice Recommendation New Zealand Newborn Clinical Network Neonatal Subgaleal Haemorrhage Practice Recommendation Prepared by: Roland Broadbent, Yiing Yiing Goh and Kitty Bach On behalf of New Zealand Newborn Clinical Network Clinical Reference Group Date: 18/5/2018 Review date: 18/5/2020 Table of Contents Background ........................................................................................................................... 1 Incidence .............................................................................................................................. 4 Prompt diagnosis and early aggressive management……………………………………………4 Risk factors for development of SGH .................................................................................... 4 Clinical manifestations .......................................................................................................... 5 Early diagnosis through neonatal surveillance…………………………………………………… 5 Algorithm for Detection and Management of Subgaleal Haemorrhage (SGH) in the Newborn ............................................................................................................................................. 6 Surveillance for SGH in the newborn infant ........................................................................... 7 Management of confirmed SGH ............................................................................................ 8 References ......................................................................................................................... 10 Appendix 1: Approximate Coagulation Reference for Newborn ........................................... 11 Appendix 2: ADHB Paediatric massive Transfusion Protocol (MTP) .................................. 12 Appendix 3: Sheet for documentation of surveillance ......................................................... 13 i Background A subgaleal haemorrhage (SGH) or subaponeurotic haemorrhage is a rare but life-threatening condition in a newborn baby. It is caused by rupture of the emissary veins, which are connections between the dural sinuses and the scalp veins. Rupture of these veins results in bleeding into the space between the galea aponeurotica and the periosteum, the subgaleal space. The subgaleal space is a layer consisting of loose connective tissue covering the entire cranial vault. This subgaleal space is not limited by sutures (Figure 1). As a SGH is not limited to sutures, in contrast to a cephalohaematoma (see Figure 2), and a large amount of blood, up to a baby’s whole blood volume, can accumulate into the subgaleal space. Therefore, a SGH in the newborn can lead to serious hypovolemia and is recognised as a rare but life-threatening condition. Figure 1: Schematic drawing of the layers of the scalp from the top down: epidermis, dermis, subcutaneous tissue, galea aponeurotica, subgaleal space, periosteum and skull bone. The emissary vein (in red) connects the dural sinuses with the scalp veins. Picture adapted from Seery, Dermatologic Surgery, 2002. Figure 1 2 Page 1 Figure 3 Figure 4 Page 2 Figure 5 Figures 2, 3, 4 and 5: Schematic drawings of the anatomical position of different swellings that can occur on a newborn head. Please note that a cephalohaematoma is not crossing suture lines. Page 3 Incidence The incidence of SGH has been estimated to be 1 in 2,000 for normal vaginal deliveries with an increase to 1 in 200 for vacuum assisted deliveries.3 In New Zealand about 18% of standard primiparae undergo instrumental delivery with vacuum delivery making up about 10% of instrumental deliveries in ADHB.4 Mortality as a result of SGH has been described to be as high as 25% but earlier or better recognition has decreased mortality to 5-14% over recent years.1 The mean time to diagnosis of a SGH is 1-6 hours after birth.1 Prompt diagnosis and early aggressive management of SGH can decrease mortality and morbidity. A Malaysian study demonstrated that a mean time to diagnosis of only 1 hour was achievable in a centre with a formal surveillance program for all babies born following exposure to vacuum assisted delivery.2 Importantly, with this earlier recognition and active management they reported mortality to be as low as 2.8%.2 Vacuum exposure or delivery with vacuum is recognised as the most important risk factor for development of a SGH, but a SGH can also develop following spontaneous, forceps or birth via Caesarian section. To enable early recognition and aggressive treatment of SGH, hopefully resulting in decreased mortality and morbidity for these babies in New Zealand, we developed the surveillance program as set out in these guidelines. Risk factors for development of SGH Compared to obstetric forceps, the vacuum extractor is easier to apply and has less maternal injuries. However, the vacuum extractor is associated with significantly more fetal injuries, including SGH. 5 Well recognised risk factors for development of SGH in a newborn are: • Vacuum delivery or attempted vacuum delivery, especially if: ❖ inappropriate placement of vacuum cup, ❖ prolonged vacuum >20 min 6, ❖ 3 or more pulls (i.e traction during 3 or more contractions), ❖ detachment of vacuum cup, ❖ performed at < 36 weeks (relatively contra-indicated at < 36 weeks and contra-indicated at < 34 weeks), • Maternal: Nulliparity • Fetal: haemophilia Page 4 Clinical manifestations SGH is a clinical diagnosis with a large, diffuse, fluctuating mass that crosses suture lines and develops in the first hour to hours after birth. Diagnosis should NOT be delayed by imaging as prompt action is necessary, and delay awaiting confirmatory tests could be fatal. • Features ❖ APGAR <7 at 5min without asphyxia ❖ Haemodynamic instability (increased HR, increased RR or WOB, pallor, prolonged capillary refill > 3 sec, metabolic acidosis, low BP) ❖ Anaemia, coagulopathy • Localised signs ❖ Generalised scalp swelling, which is movable, fluctuant or ballotable, crossing suture lines, gravity dependent ❖ Examine the supine infant by lifting head forward and using both hands behind the occiput; feel for fluctuance, try to push any swelling forward and if it moves forward freely, this indicates SGH. ❖ Displacement of ears, peri-orbital oedema ❖ Increased head circumference (late sign as approximately 35 ml of blood is needed to increase head circumference by ~ 1 cm) ❖ A 1-cm increase in the depth of the subgaleal space may contain from 40mL to 260mL of blood.7,8 ❖ A fluctuant swelling localized to one skull bone (usually the parietal bone) is a cephalohaematoma, and is benign. Pitting oedema suggests a caput succedaneum, also benign. Bleeding into the subgaleal space can lead to significant hypovolemia, anaemia and coagulopathy as a newborn’s estimated blood volume is 80mL/kg; therefore, blood loss of 48 ml in 3 Kg baby equals loss of 20% of circulating volume. Early diagnosis through neonatal surveillance The intensity of neonatal surveillance (low, intermediate or high) should be based on the perceived risk of development of a SGH and is dependent on both clinical circumstances and neonatal condition. The algorithm below is adapted from the RANZCOG College Statement C-Obs 28 with source Mercy Hospital for Women: Clinical Practice Guideline; Prevention, detection and management of subgaleal haemorrhage in the newborn.9 Page 5 Algorithm for Detection and Management of Subgaleal Haemorrhage (SGH) in the Newborn Low risk Instrumental Birth (Attempted Intermediate risk Surveillance or successful) Surveillance Is required for all • Attended by Paediatric/ Neonatal Is required for one or more of newborn infants team according to local the following: following attempted or guideline, indicated if fetal • Total vacuum extraction successful distress, need for resuscitation. time>20 minutes instrumental delivery • All babies should receive • 3 or more pulls Intramuscular vitamin K, unless • 2 cup detachments contra-indicated • 5 minutes Apgar <7 • No hats to be worn during • At clinician’s request observation period • Observation to occur in good Intermediate Surveillance light • Notify paediatric staff Low risk surveillance • Cord or venous / capillary FBC. Observations at • Cord Lactate • Birth • Consider group and hold. • 1-hour • Observations at • 4-hour o Birth o 1 and 2 hours of age o 4, 6 and 8 hours of age o 12 hours of age Refer for High risk surveillance if: • Baseline HR >160bpm or rises > 20/min • Tachypnoea RR >60 or increased work of breathing • Pallor • Poor perfusion (central capillary refill >3sec) • Concern about scalp or increase in head circumference High Risk Surveillance Is required for all newborn infants if clinical suspicion of SGH immediately following birth or signs of SGH develop at any stage High risk Surveillance • Immediate review of newborn by (senior) paediatric staff • Immediate admission to SCBU or NICU • On admission, must have urgent capillary / venous FBC, crossmatch, coagulation profile and capillary gas • Continuous monitoring of heart rate, RR and pulse oximetry • BP Q15min for 4 hours, then hourly for at least 4 hours • Insertion of IV access (2 peripheral drips or UVC) • Confirm vitamin K had been administered Observations include heart rate, colour, perfusion, activity and examination of scalp, all in a good light. Pulse oximetry is recommended (intermittently) unless High risk surveillance when it will be continuous. Page 6 Surveillance for SGH in the newborn infant Management of all babies following attempted or successful instrumental delivery: • Instrumental deliveries are often attended by Paediatrics
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